From the Department of Family and Community Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX (Dr. Zare, Ms Klawans, Dr. Moreno), Department of Family Medicine and Community Medicine, Baylor College of Medicine, Houston, TX (Dr. Mejia de Grubb, Dr. Juneja, Dr. Zoorob), Department of Psychiatry, McGovern Medical School at the University of Texas Health Science Center, Houston, TX (Dr. Suchting), andHarris Health System, Houston TX (Ms. Mathis).

Abstract

Objective: To describe a pilot project to improve care for patients with uncontrolled diabetes in a safety net clinic.

Methods: One of 3 clinical teams was designated the intervention team. Changes implemented by the intervention team included patient referral to a dietician and/or clinical pharmacist, provision of patient education, and assignment of a case manager. We compared outcomes of patients in the intervention group (n = 71), vs those receiving care from the other 2 teams (usual care) (n = 188).

Results: HbA1c significantly decreased over time for patients in the intervention group as well as the usual care group. Within the intervention group, visits to clinical pharmacist (P = 0.034) and education (P = 0.004) predicted significantly greater decreases in HbA1c over time.

Conclusions: Diffusion of treatment may account for the overall HbA1c reduction regardless of treatment group. Results support the need for further pragmatic research to weigh the impact of unblinded designs, outcome measurement, and real-world behaviors on evidence-based interventions.

The prevalence of type 2 diabetes in the United States is significantly higher among Hispanics and African Americans than in the general population (13% vs. 9.3%) [1]. Similarly, diabetes is highly prevalent among the uninsured, and many patients delay or forgo treatment due to cost [2]. Subsequently, the rates of comorbidities, including stroke, hypertension, and CVD, are elevated in these groups [3].

Association between elevated HbA1c and morbidity and mortality is well-documented, and an HbA1c reduction of just 1% has been shown to reduce mortality and improve quality of life [4]. Uncontrolled diabetes also results in increased medical costs. Reducing HbA1c from 9.0 to 7.5 reduces annual expenditures by as much as 73% [5].

Metropolitan Houston and Harris County, Texas, has one of the largest uninsured metro populations in the United States (over 3.6 million) [6]. Harris Health System serves this uninsured population and is the fourth largest safety net health system in the nation. Approximately 40,000 patients with diabetes receive care within the health system, and 34% of them have an HbA1c value greater than 9.

Developing novel, cost-efficient treatment and management models is crucial when providing care for patients with uncontrolled diabetes. However, the study of implementation strategies to successfully integrate evidence-based interventions in primary care using pragmatic approaches that aim to determine the effectiveness of interventions in “the real world” remain a challenge [7,8]. To address this issue, a quality improvement project was instituted at one of the system’s health centers to improve the care of patients with uncontrolled diabetes (known HbA1c above 9).

Methods

Setting

The pilot project was conducted from 1 Oct 2015 to 31 Dec 2015 in a primary care community health center within Harris Health System in Houston, Texas. This pilot was the first step of an institutional effort to introduce a multidisciplinary model of care across all clinics [9]. Our health center has 6 family medicine providers and 1 advanced practice nurse practitioner, organized into 3 pods with 2 physicians each. We randomly selected 1 pod (team) and designated it the intervention group.

The Standards for Quality Improvement Reporting Excellence guidelines [10] were followed and institutional review board approval was obtained.

Intervention

Practice changes introduced in the intervention team were assignment of a case manager to all patients, referral to a dietician and clinical pharmacist as needed, and patient education sessions. The team’s nurse assumed the role of case manager. The case manager was responsible for reviewing a patient checklist based on the America Diabetes Association guideline for comprehensive diabetes medical evaluation at initial and follow-up visits. Referrals were based on ADA guideline recommendations. Onsite brief patient education was provided to all patients. In addition, patients were enrolled in a “Diabetes 101” class, which follows an evidence-based curriculum that includes participation in at least 2 monthly sessions. Patients were asked to return to the clinic for a follow-up visit after 3 months in order to monitor medication compliance, re-evaluate their care plan, and measure HbA1c The usual care group patients were managed based on the current Standards of Medical Care in Diabetes [11]. The usual care group included patients from the same clinic under the care of providers in the teams that were not included in the multidisciplinary intervention.

Pages

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. Accessed at www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.

2. Casagrande SS, Cowie CC. Health insurance coverage among people with and without diabetes in the US adult population. Diabetes Care 2012;35:2243–9.